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Interviewer: So, when it comes to opioids and being prescribed opioid painkillers, do most doctors at this point in time all operate from a similar paradigm when it comes to whether they should prescribe them, whether they should not prescribe them to a particular patient? Or do patients still need to kind of have a working knowledge of opioid pain pills? Because they scare me. I hear some of these stories and they sound a little frightening.
Dr. Miller: Well, as you know, the news is out that opioids are very addictive. The statistic is something like 80% of current heroin abusers had started out on prescription opioids. And so we have a track record in this country now over the last 30 years of overprescribing opioid narcotics for the treatment of pain, and that has led unfortunately to an increase in deaths from opioids and heroin use and other bad things.
So, in answer to your question, there is not a policy about prescribing opioids that applies to all physicians. And, more importantly, we're not yet all completely on the same page about how to use and treat people with opioid painkillers.
Interviewer: Yeah. So, to some extent, the consumer, the healthcare consumer should have a working knowledge. And as somebody that might find myself in the healthcare system, how would I know whether or not it's appropriate for me if all doctors aren't operating from the same paradigm as of yet? And why is that? Why aren't they? Is it just because the information hasn't caught up to everybody yet?
Dr. Miller: I think that's part of it. They're individual prescribing practices, and some physicians don't prescribe opioids very commonly while others do. And presumably, the ones that are now prescribing opioid for pain and do quite a bit of that are well versed in how to use that, setting up contracts with their patients on how to take opioids and when to report in and when to get their refills and so forth.
So there is a spectrum of understanding of how to prescribe opioids. It starts back with medical student training and then residency training. We have not had what I would consider to be top-of-the-mark training in opioid use throughout our medical training, and that's changing over time.
Interviewer: Gotcha. Just takes a little time for that to kind of roll out, yeah.
Dr. Miller: It takes time.
Interviewer: So, back to my original question. I asked somebody who might find themselves in the healthcare system and now I'm trying to determine, "Is this really the right course of action for me or not?" how would I make that informed decision?
Dr. Miller: That's a great question. It starts with a question. So asking your physician how your pain can be best controlled is the way to start. What is the best way that you, meaning the physician, think that your pain should be treated? How do we do that?
In general, it depends on the type of procedure you're having or the pain you're experiencing. And the plan is really to start slow and use non-opioid substances or drugs, like non-steroidal anti-inflammatories like aspirin or ibuprofen or Tylenol, or other modalities, like massage or other physical therapy efforts.
Interviewer: Which I've read, and people might find this hard to believe actually can be just as effective if not more effective than opioids for chronic pain, those types of things.
Dr. Miller: That's true. Yeah, I think we were under the misassumption that opioids treated all types of pain pretty easily as a public, and that's not true. There are many other ways to treat pain. Acupuncture is another way that works well for some patients.
But again, you have to assess the severity of the problem, the potential severity of the pain. So if you have an open abdominal procedure where the muscles of the wall of the abdomen are cut, you're very likely going to have some pretty intense pain for a while.
And then you work with the physician to decide how much pain medicine you need and for how long. So, in general, shorter courses are preferred. And you don't want to be taking large amounts of opioids for a long period of time for a problem that is healing itself.
So, again, you start with questions. You start with, "What is the best way to treat the pain you might anticipate that I will have? What is your standard of practice?" or "I have this particular pain. What do you think the best way for me to have it treated is?" And then listen carefully to what they tell you.
If it starts off with a conversation that seems unclear or moves very quickly to opioid narcotics, then you might want to ask more questions about why are we starting with that particular medication rather than something that's potentially less addictive.
Interviewer: If we were to try to draw a visual path, I have the feeling that opioids might be prescribed for chronic pain, which is long, ongoing pain, like severe back pain that you're suffering from, or it could be pain that you might experience during a surgical procedure. Those would be the two different paths possibly?
Dr. Miller: Right. So there's chronic pain, pain that you can expect to have for weeks and months and perhaps years.
Interviewer: Yeah. And those are the types of things that some of these other modalities, as you said, massage, acupuncture, physical therapy, exercise could possibly mitigate and would be a better option.
Dr. Miller: Correct. At least trying that initially or working through that without using opioids initially would be a good point.
Some of the illnesses that we've gotten away from prescribing opioids would be things like migraine headaches, fibromyalgia, types of pain that are chronic, that don't really have a well-understood initiating cause or a cause that we think is going to heal over time, or pain that is episodic. If you treat that with opioids, sometimes that leads to a higher rate of addiction.
Interviewer: Gotcha. And in a surgical procedure, say I'm going to go into a surgical procedure and my physician says, "Yeah, this is going to be pretty intense for a couple of days. I'm going to recommend opioids." They're saying it right away, but they're also saying it's only going to be for a couple of days possibly. Should I be frightened of that?
Dr. Miller: No, you should not. I think most surgeons now are very well aware of the amount of narcotics that they're going to need for the particular duration of healing that you're going to experience.
If you're getting a month's worth of narcotics for a procedure that you might expect to be out of the hospital for in several days, then that is probably too much, and you could just say, "How many days do you think I'll be needing to take these medicines?" And then you might ask to say, "Look, why don't you just give me a week or two weeks or whatever you think is best for this particular healing period?"
Interviewer: Read an interesting article. The surgical department here actually did a study that found out that, as of right now, prescribing of opioid-based painkillers after a procedure is . . . they don't take the individual into consideration. Everybody would get them whereas they felt that they should talk to each patient to try to figure out what would be appropriate for that patient.
Dr. Miller: Correct. So what that study or that . . . it's not a study, but what that approach shows is just what you and I are talking about, that every patient has an individual need for the way their pain is treated and that depends on the procedure. So it depends on the type of the procedure, the length of the incision, the area of the procedure, and then the assumed time of healing.
So laparoscopic procedures, where they make very small incisions, are likely to heal quite a bit faster and would need less pain control and possibly could be managed without narcotics. Larger procedures, possibly longer periods of time, a week to two weeks, where they might need opioids. Again, it's quite individual.
And this is another thing. The science is not well worked out in terms of why one person's pain requires more and different types of analgesics than others. It's not known yet. So everybody is a little bit different.
Interviewer: And I think that brings up an important point too, that another way that people get into trouble is they are prescribed to take a certain amount over a certain time and they're like, "Well, I know my body and I don't normally react, so I'm going to take two instead of one." And with Tylenol, it's probably not a good idea, but with opioids, it's a really bad idea to start changing that dosage.
Dr. Miller: Yes. Again, we're not entirely clear why some people start on a path and then become rapidly addicted to opioids and seek opioids for the pain relief. It's not quite clear. Some people can be on opioids for some time and stop and it's not a problem. We don't really understand that completely.
Interviewer: But maybe not a gamble worth taking if you think you could . . .
Dr. Miller: Well, yeah. What we know now, given the evidence of the '90s and the last decade, is there was too much opioid prescribing, and it did lead to higher rates of addiction. So, obviously, the more opioids that are out there that people are taking for longer periods of time or perhaps in higher doses leads to higher rates of addiction.
Interviewer: So the important takeaway from this, it sounds like, is if you're finding yourself in position where that is a recommended way to deal with your pain from a physician, to start having a conversation. Because not having that conversation and just perhaps taking those pills could lead to a place you don't want to be.
Dr. Miller: That's correct, or it could lead you to have excess opioids at home, whatever type or form you have, and somebody else could maybe use that and that would lead to some problems down the road for them.
Interviewer: What about a resource if somebody wants to read a little bit more? The CDC? Is that a good place to go to learn more? Or National Institutes of Health?
Dr. Miller: CDC has guidelines, and we've actually repurposed the guidelines in our community clinic group as a training tool and an education tool for physicians in our community clinic group to read and learn from. So the CDC would be a good place to start.
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